Internal Professional VA Intake

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Internal Professional VA Intake

Speech-Language Pathologist Information
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Sales Channel*
Who is completing this intake?*
Have you previously conducted a Lingraphica device trial?*
- Yes
- No
Name of Speech Therapist*
First Last
Email*
If you have trouble receiving external emails at your va.gov email address, please consider using your personal email address. Communications will be limited to device coordination and will not include patient PHI.
Enter Email Confirm Email
Do you use your mobile phone, work phone, or both?*
- Mobile Phone
- Work Phone
- Both
Mobile Phone Number*
Work Phone Number*
Extension
How would you like us to contact you?*
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Have you participated in any of the following with Lingraphica? (Check all that apply)*
- Online CEU Course
- Live Webinar
- On-Site Patient Consultation
- On-Site In-Service
- Lingraphica Certification Program
- None
Who conducted the in-service, webinar or on-site visit?
Are you interested in scheduling a virtual in-service with a Lingraphica representative?*
- Yes
- No
How long do you expect to have this patient on caseload?*
- 1 week or less
- 1-2 weeks
- 2 weeks or more
- Uncertain (Visits depend upon continued authorizations)
- I don't know
Requested Trial Device Information
Which Lingraphica Communication Device would you like to trial?*
All of Lingraphica's communication devices have the same software. The only difference is size/form factor. To learn more about our devices, visit https://lingraphica.com/aac-devices/ 
Which accessories would you like to trial? (Choose all that apply)*
In addition to the standard case and stylus, please select up to 2 (two) accessories from the list below. Select None if you do not wish to trial any accessories. To learn more about accessories visit https://lingraphica.com/aac-devices/aac-device-accessories.
- Standard Mouse (Wireless)
- Joystick
- Stylus Tether
- Wireless Keyboard
- EZ Eyes Keyboard
- Ball Stylus
- Extended Stylus
- T Stylus
- Weighted Stylus
- Flexible Stylus with Strap
- Long Flexible Stylus
- Rugged Case (MiniTalk only)
- None (all devices come with a standard case and stylus)
Shipping Information for Trial Device
Please note: We recommend trial devices be shipped to the SLP. If you request shipping to a client or another recipient, please confirm they’ve been notified. The SLP completing the intake is responsible for the device until it is returned to Lingraphica.
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Which VA Medical Center do you work for?
In which clinical setting are you currently treating your client?*
Facility Name*
Country*
Street Address*
Street Address 2
City*
State*
State / Province*
Zip Code*
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VA Medical Center Phone
Special Instructions for Shipping
Please confirm your trial shipping information*
- By checking this box, you confirm the shipping address provided is yours (the practicing clinician), that the address is correct and someone will be there to sign for the package.
Patient Information
Patient's First Name (or Initial)*
Patient's Last Name*
Date of Birth
Last 4 digits of SSN
Gender
Pronoun
- She/Her
- He/Him
- They/Them
Phone Number
How would you like us to contact the patient?*
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Does your patient have their own email address?*
Email
Enter Email Confirm Email
Which language does the patient prefer to use when communicating with the Lingraphica team?*
- English
- Spanish
- Other
Please describe your patient's monolingualism or bilingualism*
Medical Diagnosis*
Please enter the diagnosis*
Care Partner or Support Person Information
Lingraphica will need to communicate with either the client or their care partner/support person throughout the trial process. Communication with your client's support system increases the likelihood of a positive and successful trial experience.
Who should we reach out to about the device trial?*
Are they aware of the device trial?*
Are they aware of the device trial?*
Describe your client's support system during the trial*
How does the care partner feel about the device trial?*
Name of spouse, caregiver, or support person
Phone Number of spouse, caregiver, or support person
Email of spouse, caregiver, or support person
Enter Email Confirm Email
Relationship to the Patient
- Spouse
- Parent
- Child
When can we reach out?*
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May we reach out to the caregiver/communication partner?*
- Yes
- No
- Not yet
Is there anything you would like your Clinical Consultant to know about your schedule, patient's schedule, communication preferences, etc.?

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Internal Professional VA Intake

Speech-Language Pathologist Information

Requested Trial Device Information

Shipping Information for Trial Device

Patient Information

Care Partner or Support Person Information